Antibiotic stewardship the old-fashioned way

The issue: Reducing inappropriate antimicrobial use in a community hospital.

Background

When Lisa Dumkow, PharmD, an infectious disease-trained pharmacist, was hired by Saint
Mary's in 2013 as the clinical pharmacist in charge of antimicrobial stewardship,
she had a question. “The first thing that I asked was, “Do we have the
budget to get clinical decision support [software]?” said Dr. Dumkow during
a session at IDWeek 2014, held in Philadelphia last October.

Decision support software has helped other hospitals improve antibiotic stewardship
by encouraging optimal prescribing and appropriate de-escalation, Dr. Dumkow said.
But it's expensive, at about $100,000 to purchase with additional ongoing costs. That
was more than Saint Mary's was prepared to spend. “Unfortunately, for most
community hospitals, the answer is no, we don't have the budget to get clinical decision
support software,” she said.

The lack of technology was a setback, but not an impossible one. “Our hospital
actually implemented our stewardship program without this software,” said Dr.
Dumkow.

How it works

Dr. Dumkow started her stewardship program by assessing the needs of her hospital,
going on rounds and interviewing clinicians. “What everybody was really clamoring
for was education,” she said, describing a patient she saw on her first rounds
with a urinary tract infection that was pan-susceptible. “I said, ‘Why
is that patient still on ertapenem?’…The ICU attending said, ‘We
never de-escalate. We never change antibiotics.’”

In addition to failure to de-escalate, she found that unnecessary double coverage
for gram-negative organisms was common. “We were using a lot of beta-lactams
plus fluoroquinolones,” said Dr. Dumkow.

The overuse was caused by a number of factors, including outdated protocols and a
lack of localized guidance. “The sepsis advisor in [our electronic health record]
is actually where most of our doctors were getting their recommendations for antimicrobial
therapy and had not been updated for several years,” said Dr. Dumkow. Additional
pharmacy policies were also outdated which made renal adjustment and switches from
IV to oral formulations difficult.

She worked with her team of infectious disease physicians and hospital experts to
update protocols and guidelines then took the new advice and the evidence to support
it out to the front lines. “We were kind of the stewardship pilgrims, bringing
this message to everyone about what our antibiogram currently looks like and how we
should change prescribing,” Dr. Dumkow said. “Our own data speak louder
than any words. Our critical care physicians and hospitalists were really on board
with this and said, ‘What should we be doing instead?’”

To help them answer that question in daily practice, an intranet site with stewardship
guidance was created. In addition, Dr. Dumkow along with her students and residents
review all antibiotic prescriptions around the hospital every day. “We just
call pharmacists and providers working on that floor with interventions throughout
the day,” she said.

Results

In the first 6 months, from October 2013 to March 2014, Dr. Dumkow's team made 1,575
recommendations to change prescribing, and 91% of them were accepted. “About
half of them were de-escalation or discontinuation of therapies. I did a PO switch
in 17%, a dose optimization in 14%,” she said. More than a third of the suggestions
were made through other pharmacists working with their specific patient care team
who were not specifically trained in infectious disease, she noted.

As one might expect, the hospital's prescription patterns changed during that time,
too, to use less broad-spectrum drugs. “We had significant decreases in carbapenem
usage—meropenem, ertapenem. Also, for the fluoroquinolones, specifically levofloxacin,
we decreased our utilization by approximately half,” said Dr. Dumkow.

Clostridium difficile infections also decreased. “Our rate prior to antimicrobial stewardship was
17 cases per 10,000 patient-days. Our rate post was 11.4. In June of [2014], we actually
only had 1 case, so our rate was only 1.3 for 10,000 patient-days,” said Dr.
Dumkow.

Next steps

The stewardship program also reduced costs, saving over $200,000 in its first year
of operation. That was enough money to get Dr. Dumkow the stewardship tool that she
wanted from the start. “We actually just got approved for clinical decision
support software,” she said. The program may also get some allocated time from
an infectious disease physician.

Words of wisdom

This project proves, however, that stewardship is possible, even without dedicated
time from infectious disease specialists or expensive computer systems, Dr. Dumkow
concluded. With training and authority, all hospital pharmacists can play a key role
in improving inpatient antibiotic prescribing.

“These pharmacists are often familiar with the hospital formulary and antibiogram,”
she said. “They can alert you to missteps that are being taken with antimicrobial
prescribing at the time, instead of retrospectively having to go back and look at
those patients.”

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.